BLOCK

4 THEME B: Treatment Planning Issues in the Child

PROBLEM 5: Bombed Out
Space Maintenance & Early Loss of Primary teeth

Importance of Treatment Planning:

Correct Dx of pulp status is the most important factor in success of treatment (Rodd et al 2006)
Good Hx
Correlation between symptoms and pulpal status is quite poor (Guthrie 1965)
Seltzer and Bender 1984 found high rate of irreversible pulpitis with spontaneous pain
- Pulpotomy not recommended with any unprovoked pain
Duggal 2002 said if 1/2 buccolingual intercuspal distance has carious breakdown there are
likely to be inflammatory changes in pulp horn
- Conservative pulpal therapy needed

Diagnosis of Pulpal Involvement

Significant pulpal inflammation
Pain on biting (pressure)
Hx of spontaneous severe pain, particularly at night sleepless nights
Necessity for analgesics
Clinical extent of caries, breakdown of marginal ridge
Presence of intra-oral swelling/sinus
Hx of extra-oral facial swelling

Investigations
Palpate for mobility or tenderness
Pulp sensitivity testing unreliable
Radiographs - extent of caries
o proximity to pulp horn
o p.a. pathology
o resorption
o presence of successor

Indications for retention

Medical Factors
Risk from xla (bleeding disorders (warfarin can't be >3), hereditary angio-oedema
Risk from GA: cardiac conditions, cystic fibrosis, muscular dystrophies

Dental Factors
< 3 extensively carious molars that require pulp therapy
Hypodontia
Prevent mesial migration of 6's

Social Factors
Regular attender
Good compliance
Positive parental attitudes

Indications for removal (UK NICE Guidelines)

Medical Factors
Risk from residual infection eg immunocomprimised (Crohns, juvenile chronic arthritis,
renal/heart disease), susceptibility to IE, congenital heart defect, digoxin 30% sucrose high
caries rate
Extensive pathology/facial swelling (medical emergency)

Ambrish Roshan Page 1

 Dental Factors
>3 carious teeth with pulpal involvement
Unrestorable tooth
Extensive internal root resorption
Tooth close to exfoliation (>2/3 root resorption)
Contralateral tooth already lost

Social Factors
Irregular attender
Poor compliance
Unfavourable parental attitudes

Pulp Therapy
Diagnosis of Pulp Status
Pulp inflammation sets in early for proximal caries, and precedes the exposure of the pulp
Evidence that pulp inflammation is already present in cases where proximal caries involves
more than half the width of the marginal ridge or more than half the depth of dentine, even
before the pulp is clinically exposed
Bacteria can penetrate the wide dentinal tubules and reach the pulp ahead of the carious lesion
and cause pulpal inflammation
History of pain and discomfort is carefully assessed
Pain that makes the child cry, lingers or wakes the child up at night is indicative of irreversible
pulpitis
apy Pulpotomy (86% success over 3 years)
Definition: Removal of coronal pulp, which is deemed to be inflamed, thereby leaving the healthy
radicular pulp in situ
Restoration that provides an excellent coronal seal to prevent reinfection of the remaining pulp
tissue is then placed
Cvek Pulpotomyminimal coronal pulpal removal until haemostasis achieved

Indications
Deep proximal caries
No history of spontaneous or persistent pain, or evidence of infection, such as furcation
radiolucency provoked on short duration, sharp pain i.e. REVERSIBLE PULPITIS
Relieved with analgesics and on brushing
Instances where extraction might not be desirable (patients with haemophilia and other bleeding
disorders)
Contraindications
Figureheart
Children with congenital 21.4 disease
Radiograph showing furcation pathology present in upper first
Immunosuppression.primary molar. Infection in primary molars always manifests in the furcation
region due to presence of accessory communications between the pulp and
IRREVERSIBLE PULPITIS
furcation region.

g example of marginal ridge

ally inflamed and a pulpotomy is

Exposure and

Ambrish Roshan Figure 21.5 Removal of the coronal pulp using sharp excavators. Page 2

Exposed
Not Exposed
Pulpotomy medicaments
Only carried out if the pulp inflammation is suspected to affect the coronal pulp and the
radicular pulp is deemed healthy
Use of a fixative, such as formocresol, is not indicated and should not be used
Concerns regarding its toxicity
Last decade excellent results have been reported with 15.5% ferric sulphate (AstringidentR)
MTA has also been used successfully but its cost remains prohibitive

Medicaments
1. 15.5% ferric sulphate, 20% Buckleys formocresol, MTA paste, pure CaOH powder
2. Formocresol and ferric sulphate have similar success rates (Srinivasan 2006)
3. In 2004 the international agency of research on cancer stated there was sufficient
evidence that formaldehyde causes nasopharnygeal cancer in humans

Ferric Sulphate
Fe2(SO4)3, 15.5% conc, pulpal haemostasis
Astringent as liquid/gel which forms a ferric protein complex that mechanically occludes
capillaries forming a protective metal-protein clot
>90% success rates at 2 years (86+%)

Pulpectomy
Definition: Gaining access to the root canals, removal of inflamed or infected tissue and filling the root
canal with a suitable material that will help preserve the primary tooth in the arch in a non-infected state
Indications
Primary molars that have irreversible pulpitis
Primary teeth with necrotic pulps
Evidence of furcation radiolucency on the radiographs
Presence of a chronic or acute abscess where tooth needs to be maintained in the arch. In many
such situations extraction could also be considered as a valid treatment option and a pulpectomy
is carried out if the preservation of the primary molar is deemed essential.

Stainless steel crowns (SSC)

Most successful restoration for carious primary teeth
Long lasting and versatile enough to be used in many situations for the restoration of the
primary dentition and also permanent molars in children and adolescents
Supplied only by 3M ESPE.

Indications
Restoration of primary molars with caries involving multiple sur- faces
Restoration of primary molars after pulp therapy or after indirect pulp capping
Children with rampant caries who will benefit from full coverage
Restoration of primary molars with developmental defects. Particu- larly useful for the
protection of the primary dentition in cases of amelogenesis and dentinogenesis imperfecta
Restoration of extensively carious primary molars in pre-schoolers where a truly long lasting
restoration is required
In children with disabilities with severe bruxism that is causing damage to the dentition. SSCs
protect tooth surface wear in these situ- ations and often need to be placed under general
anaesthesia
Restoration of hypomineralised permanent molars, such as occur in cases of molar incisor
hypomineralisation (MIH)

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 dentinogenesis imperfecta.

Figure 22.2 SSC used to restore upper first primary molar after pulpotomy.

r primary molars (a) (b)

(a) (b)
Figure 22.6 Tooth prepared for placement of SSC. Note reduction of only
Advantages proximal and occlusal surfaces (a) before seating the selected crowns (b).
Figure 22.3 SSC used to restore hypomineralised primary second molars.
Low failure rate
o Once placed SSCs seldom come off
o Failure rates of less than 5% over 5 years have been reported
Easy to place
o Once the technique is learnt, it takes less time than preparing and placing a class 2 restoration
with composite resin
Cost-effective (b)

ace caries. o Because of ease of placement and low failure rates it is the most cost-effective
restoration.
o Repeated replacements of restorations in children has implications for the childs
behavior
Figure
o 22.5InSSC
view ofrestore
used to the very
primarylow
molarsfailure rates
in a patient with reported with SSCs all clinicians who treat children
dentinogenesis imperfecta.
should be familiar with this technique (a)

Figure 22.7 Aesthetic crowns (NuSmile). Tooth preparation (a) and

Pre-veneered NuSmile
Figure 22.4 SSC used crowns
to restore primary (Fig.
molars 22.7)with
in a patient placement of the NuSmile Crown (b). Courtesy of Dr Karin Ziskind, NuSmile
amelogenesis imperfecta. Crowns.
Can be used for primary molars
For those who are concerned about aesthetics
t primary molar after pulpotomy.
Technique differs from the traditional SSC preparation
Paediatric Dentistry at a Glance, First Edition. Monty Duggal, Angus Cameron and Jack Toumba. 2013 John Wiley & Sons Ltd. Published 2013 by Blackwell Publishing Ltd.

Considerbly more tooth preparation is required

48 Chapter 22 Crowns for primary molars
Tooth should be reduced occlusally and proximally, but also buccally and lingually/palatally
About 30% tooth reduction is required to accommodate the crown and to create subgingival
feather-edge margins
Once learnt and with a little practice the technique is easy to use for a specialist paediatric
dentist (a) (b)
Aesthetic outcome is excellent
Figure 22.6 Tooth prepared for placement of SSC. andNote
thereduction
resin ofveneer
only is durable and the crown long lasting if
ralised primary second molars. cemented with glass
proximal and occlusal surfacesionomer cement.
(a) before seating the selected crowns (b).

(b)

(a)

Figure 22.7 Aesthetic crowns (NuSmile). Tooth preparation (a) and

molars in a patient with placement of the NuSmile Crown (b). Courtesy of Dr Karin Ziskind, NuSmile
Crowns.

onty Duggal, Angus Cameron and Jack Toumba. 2013 John Wiley & Sons Ltd. Published 2013 by Blackwell Publishing Ltd.

molars

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 Hall technique
Definition: Without using local analgesia, the crown is seated forcibly with finger pressure, or
with the child biting down on the crown.
Does not cause excessive discomfort for the child
Once the crown is cemented caries progression slows or stops due to the nature of the seal, and
deprivation of substrate for the bacteria

Atraumatic restorative technique (ART)

Definition: Conservative procedure where some caries is removed without local analgesia and
then a restoration such as glass ionomer is placed on top
Useful way to stabilise the carious dentition while a full treatment plan is drawn up and final
restorative care is provided
Sometimes poor restorations in primary molars have been clothed in a respectable garb (ART)
(Fig. 23.3)
Mainly in areas with poor access to conventional restorative care
Should not be considered as a routine method for restoration of primary molars
the first permanent molar
Reasonable survival has been reported for occlusal restorations, extremely poor results are
consistently reported for proximal cavities
o Over two thirds of the restorations lost over a 1224-month period
o Use of ART approach to multi-surface restorations should not be considered routinely

Figure 24.2 Maxillary left first permanent molar fissure sealed with a glass
ionomer cement (GIC).

Indications for use of ART

ent molar
Interim restoration of carious primary teeth in pre-cooperative children
Only for teeth with low risk of pain and infection, mainly on caries affecting occlusal surfaces
(Fig. 23.4)
Restoration of arrested caries (Fig. 23.5)
Temporary stabilisation of the dentition until definitive treatment is carried out

Indirect pulp capping (IPC)

Restoration of a large proximal cavity
One of the reasons for frequent failures associated with placing proximal restorations in
extensively decayed primary molars is that pulp inflammation sets in early for proximal caries,
and precedes the exposure of the pulp
Should only be carried out in such situations if the patient has been free of any symptoms of
pulpitis or if a certain diagnosis of reversible pulpitis can be made
All other situations a pulpotomy should be considered even if the pulp is not considered to be
clinically exposed.

Indications for indirect pulp capping

Deep cavity but a certain diagnosis of reversible pulpitis
erupted mandibular first permanent molars
Low caries fissure
risk children
with low caries activity and caries attack rate
No history of previous abscesses

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Rationale for space maintenance in the mixed dentition
Space maintenance: Preservation of spaces occupied by the 1 teeth prior to the eruption of
their successors to prevent/ alleviate future crowding.
Erupting permanent incisors larger MD than the 1 teeth; children usually have crowding of the
lower perm incisors @ 8-9yrs, then spaced due to:
1. Increased width of the dental arches
2. Freeway space
3. Labial positioning of perm incisors
4. Distal movement of the perm incisors

Space occupied by 3 + 4 + 5 < c + d + e

e 2mm wider than successor
e 1.5mm wider than 5

Loss of space
Early XLA of teeth
- if interproximal caries are present before xla, space loss may have occurred earlier
Determine space loss using Moyers Tables can estimate the widths of 3,4,5 from
widths of lower 2,1 varies for different races
Space loss usually occurs within 6mths after xla
Check XRay to see the root development of successor - ?close to eruption
Should preserve space, prevent o/e of opposing teeth, tipping of adj teeth.

NICE Guidelines 2002

Space maintenance to be used in loss of all E but a spaced arch
Loss of D ( if more than 3.5mm of crowding per quadrant)

Types of maintainer (Fixed/Removable & Unilateral/Bilateral)

1. Band & Loop
0.8mm wire loop soldered to molar band
Only for one tooth e.g. d
Loop should allow for tooth to erupt into it
Should not affect occlusion/mastication

2. Distal shoe
When e is lost prior to eruption of 6
Metal/ plastic guide along which 6 can erupt
Can be attached to fixed/ removable appl
Difficult to make

3. Lingual arch space maintainers

Where multiple 1 post teeth missing & lower incisors have erupted fitted into
molar bands
0.9-1mm wire along cingula of perm teeth 1.5mm from ST
C/I in deep OB (use Nance)
Break easily

4. Nance
Wire embedded into acrylic button on ant hard palate
May cause irritation

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 0.9-1mm wire soldered into bands
Unilateral/ bilateral loss of teeth

5. Transpalatal arch
Across palatal vault posteriorly, not in contact with palatal mucosa
Indicated for unilateral loss where opposite side is intact
0.9-1mm wire into bands
Passive
6. RPD maintainer
Bilateral loss of more than one 1 tooth before eruption of the perm teeth
Good for aesthetics anteriorly
Must have cribs/ spurs around acrylic tooth to prevent space loss if the tooth is
lost
Needs good compliance and multiple clasps for retention
7. Hawley
Adams cribs on the 6 and outer labial bow with adjustable loops
Bilateral loss of one 1 molar in the presence of perm incisors
Good compliance reqd
Disadvantage of space maintenance:
Long treatment time reqd must have excellent compliance and recall
*excellent OH reqd*

Space Maintenance

Limitation of localized crowding

Maintenance of space for eruption of permanent successors
Maintenance of space for future prosthesis

Decision to fit space maintainer must find the balance between the potential benefits of
intervention and the harm caused by plaque accumulation and increased susceptibility to caries

Most space loss occurs in the first few months following tooth loss - NB to place appliance as
soon as possible after xla

Effects of early tooth loss depends on:

Patients age
Degree of crowding
The tooth extracted
The arch
The type of occlusion

Potential for crowding is greatest in young child with pre-existing crowding, when a maxillary
posterior tooth is removed with poor buccal segment intercuspation

Incisors - Tend to drift mesially if there is space mesially

Canines - Unilateral loss of primary canine always causes centreline shift and should be

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 balanced
First Molars
2nd molars drift mesially even if unerupted
Greater degree of movement in 8-10yr olds
Premolars undergo distal drifting but all teeth anterior to the molar will
undergo movement
Contacts open and premolars rotate as they fall distally
When max 1st molar loses its opponent it erupts at a faster rate and pulls
alveolar process with it ] Deflective contacts

2nd Deciduous Molars - xla causes mesial migration of 1st perm molar and leads to
considerable space loss
Loss of lower
Loss of a 1st primary molar affects anterior segment more than 2nd primary molars
Indications
1. Central Incisor - traumatic loss of upper incisor
2. Intact arch with just enough space/overcrowding ie space would promote crowding in an
otherwise acceptable occlusion
3. In severely crowded mouth where all extraction space is needed for alignment of
remaining teeth
4. If it simplifies future tx and reduces need for orthodontic extractions

Contraindications
1. Spaced arch
2. Poor OH
3. Moderate overcrowding which requires xla
Different types of space maintainers
Fixed Removable
Natural tooth Partial Denture
Bonded avulsed tooth Upper removable appliance
Stainless steel tube on archwire
Distal shoe (SSC and loop)
Band and loop
Transpalatal arch
Lingual arch

Complications of Space Maintainers

Breakage
Failure of cementation of bands or solder failure
Pain or discomfort on placement
Caries
Soft tissue overgrowth
Interference with the eruption of perm teeth if incorrectly made
NB to place wire stops either side of prosthetic teeth to prevent acrylic wear and furthur space
loss

Band and Loop Maintainer

Used when there is a posterior abutment. Ideal for loss of 1st and 2nd primary molars
and canines

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Advantages Disadvantages
- Easy and economical - Does not restore chewing function
- Takes little chairtime - Doesn't prevent overeruption of opposing teeth
- Adjusts easily to accomodate changing dentition

Stainless Steel crown and loop maintainer

Used if posterior abutment has extensive caries or has had pulp therapy
Main disadvantage is difficult to remove crown to make adjustments in loop - some
dentists adapt band over cemented crown
Passive Lingual Arch
Multiple loss of primary teeth in max/mand arch and to manage leeway space

Advantages Disadvantages
- Fixed therefore good co-operation - Does not restore function
- Very little breakage - Does not restore aesthetics
- Excellent Retention
Consists of molar bands with a 0.36 or 0.40 inch steel wire contacting cingulum areas of
incisors and extending along middle third of lingual surface of molar bands
Distal Shoe Appliance
Designed by Roche, it is used to maintain space and influence the active eruption of the
first permanent molar in a distal direction
Used where there is loss of the 2nd primary molar before eruption of the 1st perm
molar

Consists of - crown and band appliance with

- distal intragingival extension
Gingiva tolerates it well although a small metallic tattoo in gingiva may result

Contraindications
- If several teeth are missing
- Poor OH
- Lack of co-operation
- Medical conditions (blood dyscrasias, immunosuppression, CHD, hx of rheumatic
fever, diabetes, generalized debilitation)

Removable partial dentures

Often used with adams clasps for extra retention

Advantages Disadvantages
Aesthetics Cooperation from pxns and parents NB
Restores normal function Breaking is a problem
Replaces multiple teeth C/I in caries
Can be adjusted to allow for eruption

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Fixed Appliances
Stainless steel tubes
Helical finger springs
Move teeth, 1-1.5mm every 3-4 weeks corrected

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